Spencer Psychology

Enrollment Agreement

When enrolling as a client Spencer Psychology, you agree to the following:

Consent for Treatment

I agree and consent for myself (or my minor child) to participate in the mental health services or evaluation offered by the staff of Spencer Psychology.

I understand that I am consenting and agreeing only to those mental health services or evaluation that the provider is qualified to provide within the scope of the provider’s license, certification, and training.

I understand that while unlikely, therapy can potentially worsen symptoms and outcomes cannot be guaranteed.


In general, the privacy of all communications between a client and a mental health provider is protected by law. Information can only be released with your permission. There are exceptions to this:

There are some situations in which a provider is legally obligated to take action to protect others from harm, and confidential information about you can be released. For example, if there is information that a child, elderly person, or disabled person is being abused or neglected, a report is made with the appropriate state agency.

If a client is threatening serious bodily harm to another, protective action must be taken. These actions may include notifying the potential victim (a “duty to warn”), contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, or through significant mental health symptoms is at risk to harm himself/herself, the provider may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

In most legal proceedings, the client has the right to prevent the provider from releasing information about treatment. However, if the provider receives a court order from a judge the records or information must be released. In some proceedings involving child custody or CHINS cases, and those in which the client’s emotional condition is an important issue, a judge may also order testimony in court if the judge determines that the issues demand it.


We do not allow recordings of sessions, as recordings can jeopardize confidentiality and trust. If we learn you have recorded a session, posted a recording on social media, or used a recording in any way, including in court, you agree to pay $1000 per hour of recording. Your services will also be discontinued.

Internal Consultation

Therapists at Spencer Psychology are all part of the same practice, and may share treatment information internally with another of our therapists for the purpose of consultation, supervision or coordination if needed for your case. This could include second opinions on treatment options, diagnoses, or seeking suggestions to improve their delivery of your care. If you and your partner/spouse/child/family member are both clients at the practice, your individual therapists may consult about shared family dynamics or crises.

No Secrets Policy

When working with couples, in conjoint sessions or family sessions, you agree that information you discuss can be shared with others you bring into your sessions.

No Show/Late Cancellation Policy

Email, Cell Phone, Social Media and Fax

Please notify the provider if you decide to avoid or limit, in any way, the use of any or all communication devices, such as email, cellphone or faxes.

Email: If you choose to communicate by email, be aware that all emails are retained in the logs of the Internet service providers on both your end and the providers' end. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails received from you and any responses that are sent by the provider can be retained as part of your clinical chart. All email exchanges can be subpoenaed in a court proceeding.

Texting: Please limit texting contacts to scheduling issues, or to request a phone call if there is an issue that needs our attention. We cannot effectively manage counseling issues by text. Some clinicians may charge for texting/emailing outside of appointments if anything other than cancelling/rescheduling.You may use our texting service to ask billing questions or to schedule. This will go to our support staff (not your therapist).  The number is (866) 222-1629.

Social Media:  To protect privacy, we cannot accept friend requests on social media sites.

Online Reviews:  We reserve the right to respond to false reviews or complaints if made on a public forum or online.

Crisis Issues

After-Hours Care/Hospitalizations:  Our practice is not designed for clients who frequently need crisis care, and we do not have clinicians on-call. If you have been hospitalized recently, or have issues with frequent suicidal thoughts or behaviors, please discuss this with the therapist during your initial session so that we can determine if our practice is an appropriate match for your needs. After-hours emergency calls will be answered, and you will typically be directed to the hospital for care.  Insurance will not cover the clinician’s time tending to this issue. This time is billed at a self-pay rate of $150 per hour (it is prorated if there is less than an hour spent).

Non-covered Services Policy

Case Management Requests: If you request additional services outside of therapy sessions (such as crisis services over the phone, or reports to outside parties), these services are not a benefit of your health insurance coverage and will be charged out of pocket. Routine coordination, such as updates to your family doctor, are not charged.

Court Services: Court appearances require extensive preparation, whether court is cancelled or continued, and the time required on the day of court is not predictable. Clinicians must cancel all of their clients that day if required to appear. A charge of $2,000 per day, per staff person, is charged for any legal proceedings including depositions. Please note that provisionally licensed clinicians (LMHCAs, LSWs and some PhD/PsyDs if without an HSPP endorsement), will not appear without their licensed supervisor, so both clinicians will go. This fee is taken as a retainer when the subpoena is issued, and payment is required by the party who has issued the subpoena. A retainer is also required at least one week prior to any court appearance. An itemized statement will be provided after the service has been completed, and any underestimate of the fee will then be charged. If the retainer has overestimated the time needed, a refund will be issued.


I authorize the release of any medical or other information necessary to process payments for insurance claims, as well as information necessary to process delinquent accounts with an attorney, small claims court or collection agency. If I have made arrangements with a parent or other party to pay my bill, I give permission for communication related to the bill to occur with the other party. This may include the other party seeing an invoice of my services, which includes diagnosis code and dates of services.

Your insurance company may require us to release progress notes and treatment plans in an audit, and releasing these notes is a requirement both as a member of the insurance for you, and as a provider for us. We do not have any recourse to refuse. No release from you is required by the insurance or by privacy practices/HIPAA. This can include notes for any self-pay services as well, if you filed a claim for reimbursement for out of network benefits.

Secondary Insurance: We do not file claims for secondary insurance. All deductible payments and co-payments for your primary insurance are still due at the time of service. Occasionally, primary insurance will send the claim on to your secondary carrier automatically. If we receive an automatic payment, you will be refunded the amount we received. If you wish to file secondary insurance yourself, we can supply you with an invoice for your services to submit to your secondary carrier. If this processes correctly, your secondary insurance should send the payment directly to you. If the claim is denied, Spencer Psychology is not responsible for follow up. Medicaid plans do not allow you to file the insurance yourself at all. If your secondary insurance is through Medicaid, we cannot see you.

Insurance Changes: It is your responsibility to understand your insurance benefits and coverage, and is not the liability of the practice. If your insurance does not cover your services, you are responsible for the self-pay charge of that service ($150 per hour).

Clients are responsible to keep us informed of any change in insurance, and to give us correct insurance. We will bill a new insurance from the date we are notified, and cannot backdate submissions. Clients will owe self-pay rates for any denied sessions due to incorrect insurance information.

Payment: Payment is due at the time of service. If you do not pay your bill in a timely manner, we reserve the right to send you to collections for the balance due and any collection company fees that are incurred.t is your responsibility to understand your insurance benefits and coverage, and is not the liability of the practice. If your insurance does not cover your services, you are responsible for the self-pay charge of that service ($150 per hour).

Other Office Policies

Client Name:
Electronic Signature of Client/Parent/Guardian: